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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pre &#40;A&#58; sagittal&#44; B&#58; axial&#41; and post &#40;C&#58; sagittal&#44; D&#58; axial&#41; MR image&#46; Yellow arrow&#58; the lesion of disc herniation&#59; yellow ring&#58; the removal site of disc material&#59; red arrow&#58; skin incision site&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Of several types of intervertebral disc herniation occurring in the lumbosacral spine&#44; the most universal is intracanal paramedian disc herniation&#44; which constitutes 93&#37; of the total cases&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">1</span></a> Additional types include disc herniations that can occur in the neuroforamen or the extra-foramen&#46; In these types of disc herniation&#44; the conventional interlaminar approach cannot resolve lesions&#59; instead&#44; the extraspinal intertransvertebral approach is mainly used&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">1&#8211;4</span></a> Although rare&#44; the surgeon may face a double lesion consisting of an intracanal spine lesion broadly involving the foramen or the extraforamen &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; In such a case&#44; total facetectomy or fusion surgery is performed to address both lesions&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#8211;7</span></a> but a combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#44; which is cost-effective and less invasive&#44; may also be utilized&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a> Because in most cases at the lumbosacral &#40;lumbar 5 &#40;L5&#41; &#8211; sacrum 1 &#40;S1&#41;&#41; level&#44; the isthmus and the facet joint are located in the exterior to the intervertebral foramen&#44; partial facetectomy is often performed in the conventional paraisthmic approach &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In cases with a double lesion&#44; medial facetectomy is performed in parallel&#44; and so the risk of instability is high following CIPA at the L5-S1 level due to facet joint disruption or post-operative spondylolysis&#46; Accordingly&#44; in the present study&#44; the authors aimed to introduce the extreme lateral and interlaminar approach &#40;ELIA&#41;&#44; which can minimize facetectomy to prevent postoperative instability in cases with a double disc herniation at the L5-S1 level&#44; and to compare the approach with the conventional CIPA procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level &#40;lumbar 5-sacral 1&#41; between March 2012 and February 2016 at the study hospital&#46; Only those patients who underwent CIPA or ELIA were selected&#46; The present study was a retrospective study&#44; and was conducted based on patient records&#44; surgical records&#44; and imaging data&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; The presence of spondylolysis and instability was determined using dynamic X-ray&#44; and double disc herniation was diagnosed using MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; CT was performed as a secondary test&#44; and the presence of a limbus fracture or a calcified disc in the endplate was examined using the CT&#46; In addition&#44; patient gender and age&#44; the length of post-operative follow-up&#44; the surgical approach used&#44; and whether a reoperation was performed were considered&#46; For postoperative outcomes&#44; the groups who underwent CIPA and ELIA&#44; respectively&#44; were compared with respect to the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation&#46; Patients showing spondylolysis&#44; spondylolisthesis&#44; or instability were excluded&#46; All surgeries were performed by one surgeon&#46; The institutional review board approved this study &#40;IRB No&#46; NR-IRB 2016-021&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Statistical analysis was conducted with SPSS 12&#46;0 for Windows &#40;SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Postoperative K-ODI and NRS were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; and whether a reoperation was performed in the groups was compared using Fischer&#39;s exact test&#46; Statistical significance was noted if the <span class="elsevierStyleItalic">p</span> value was less than 0&#46;05&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients were placed with prone position&#46; And the procedure was done under general anesthesia&#46; First&#44; the herniated disc material was removed in the intracanal area using the standard interlaminar approach&#46; To prevent postsurgical spondylolysis that can occur due to excessive laminotomy&#44; laminotomy at L5 was minimized as much as possible&#46; All the procedure of laminotomy and discectomy were performed by using surgical microscope&#46; Decompression at the S1 root was confirmed by performing laminotomy in the upper portion of the sacral laminar&#46; Subsequently&#44; an extreme lateral approach &#40;ELA&#41; was performed to decompress the L5 root pressured in the intervertebral foramen&#46; The angle at which to access the intervertebral foramen without violating the facet joint and the appropriate location for making the skin incision were determined using a preoperative MRI image&#46; The skin incision was performed approximately 7&#8211;9<span class="elsevierStyleHsp" style=""></span>cm away from the midline &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; While the approach angle was roughly estimated&#44; the paraspinal muscle was obliquely dissected and then the facet joints at L4-5 and L5-S1 were examined&#46; Afterwards&#44; a self-retaining Magana retractor was used and the isthmus at L5 was examined by sufficiently dissecting the muscle&#46; In the absence of facet joint hypertrophy&#44; access at an oblique angle enabled the examination of the lower portion of the facet joint&#44; where the root was passing through&#44; via muscle and ligament dissection&#46; The L5 root was immediately examined through a sufficient and careful dissection of the ligaments&#46; To prevent L5 nerve root injury during dissection of the intervertebral ligament&#44; we started dissection at the caudal portion where L5 nerve root did not exist&#46; Upper portion&#44; especially at the junction of L5 transverse process and isthmus&#44; L5 nerve root usually passes through&#46; After finding out perineural fat zone&#44; we did meticulous dissection to check L5 root and L5 pedicle&#46; After the L5 root and L5 pedicle were examined&#44; the root was carefully retracted to examine the herniated disc material and then&#44; the disc material was removed &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; For complete root decompression&#44; the sacral ala was partially removed in the extraforaminal area and finally&#44; the freely moving root was examined&#46; If hypertrophy due to arthropathy in the facet joint was present&#44; only a partial removal of the lower portion of S1 superior facet provided sufficient visibility&#46; In some cases&#44; visibility at the skin incision site was obstructed by the iliac bone&#44; in which case a small portion of the iliac bone was removed to obtain visibility at the site&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 35 patients underwent CIPA or ELIA at the study hospital to treat a double disc herniation at the L5-S1 level between March 2012 and February 2016&#46; Of those&#44; 14 patients were male and 21 were female&#44; and the mean age was 63&#46;4 &#40;&#177;13&#46;7&#41; years&#46; In the ELIA group&#44; there were a total of 11 patients &#40;three men and eight women&#41; and the mean age was 63&#46;0 &#40;&#177;13&#46;9&#41; years&#44; while in the CIPA group&#44; there were a total of 24 patients &#40;11 men and 13 women&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The mean follow-up length was 11&#46;1 &#40;&#177;4&#46;7&#41; months in the ELIA group and 18&#46;3 &#40;&#177;10&#46;1&#41; months in the CIPA group&#46; The mean operation time was 88&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;14&#46;5&#41; in ELIA and 86&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;10&#46;1&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;652&#41;&#46; The preoperative K-ODI score was 34&#46;1 &#40;&#177;3&#46;3&#41; months in the ELIA group and 32&#46;4 &#40;&#177;4&#46;0&#41; months in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;23&#41;&#46; Postoperative K-ODI scores in the ELIA and the CIPA groups were 8&#46;2 &#40;&#177;4&#46;1&#41; and 8&#46;1 &#40;&#177;3&#46;2&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;97&#41; at month one&#59; 6&#46;4 &#40;&#177;2&#46;1&#41; and 7&#46;1 &#40;&#177;3&#46;5&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;54&#41; at month two&#59; and 5&#46;3 &#40;&#177;2&#46;4&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41; at month three&#44; respectively&#46; Thus&#44; only the postoperative K-ODI scores at month three showed a significant between-group difference&#46; Additionally&#44; the preoperative NRS score was 8 &#40;&#177;0&#46;9&#41; in the ELIA group and 8&#46;6 &#40;&#177;1&#46;0&#41; in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41;&#46; Postoperative NRS scores in the ELIA and the CIPA groups were 2&#46;4 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;&#177;1&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41; at month one&#59; 2&#46;2 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;1&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;063&#41; at month two&#59; and 2&#46;0 &#40;&#177;0&#46;9&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41; at month three&#44; respectively&#46; Again&#44; only the postoperative NRS at month three showed a significant between-group difference &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were four patients who underwent reoperation&#44; all of whom belonged to the CIPA group&#46; In those cases&#44; the mean time interval was 12&#46;8 months&#46; Three patients suffered from recurred lumbar disc herniation and one patient had foraminal stenosis&#46; All lesions were due to post-operative instability&#46; All patients underwent posterior intervertebral body fusion surgery&#46; The proportion of reoperation was 0&#37; in the ELIA group and 31&#46;4&#37; in the CIPA group&#44; and the <span class="elsevierStyleItalic">p</span>-value was 0&#46;29 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The intracanal and foraminal lumbar disc herniation lesions can cause double radicular compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;9&#44;10</span></a> Such lesions are difficult to treat with surgery&#46; Several surgical techniques have been introduced in the treatment of double lumbar disc herniation&#46; The simplest is to remove the intracanal disc material following the interlaminar approach and then to remove the disc material of the foraminal lesion following extended medial facetectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;11&#8211;13</span></a> However&#44; in this approach&#44; the extra foraminal lesion is not accessible and&#44; even though an attempt is made to remove the disc material of the foraminal lesion&#44; it is highly likely for some to be left behind&#46; Another disadvantage is that if medial facetectomy is excessively performed&#44; the risk of instability is high due to postoperative spondylolysis or facet disruption&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;14&#8211;16</span></a> Accordingly&#44; some authors have recommended performing total facetectomy in parallel&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;6&#44;13&#44;16</span></a> However&#44; this approach has also been criticized because of a high risk of postoperative instability or chronic pain after surgery&#46; Thus&#44; there are authors who recommend performing intervertebral fusion surgery after total facetectomy to treat double lumbar disc herniation&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;17</span></a> Notably&#44; though&#44; fusion surgery takes a relatively long time and causes a large amount of blood loss&#44; increasing the risk for various complications&#46; It is also expensive&#46; For direct access to the foramen&#44; pars interarticularis fenestration has been introduced by Di Lorenzo and colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> but this approach is disadvantageous in that only limited exposure is possible&#44; and that there is a concern about a postoperative fracture of the pars&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Hence&#44; the CIPA approach was introduced by some authors&#44; and many advantages of the approach have been highlighted&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8&#44;20&#44;21</span></a> In CIPA&#44; the transversing root and the exiting root are simultaneously visible&#44; and the lesion can be removed without destroying the facet joint&#44; resulting in a low likelihood of postoperative instability&#46; Particularly&#44; the paraisthmic approach is a very useful surgical technique&#44; as access to the foramen is possible only with a partial removal of the superior-lateral portion of the facet joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#8211;25</span></a> However&#44; the problem is that when this approach is used at the L5-S1 level&#44; excessive facetectomy or excessive removal of isthmus can happen&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#8211;28</span></a> The lateral pars at L5 are located up to the outer portion of the intervertebral foramen&#44; unlike those at other levels&#44; and thus&#44; an excessive removal of isthmus is necessary to completely expose the foramen&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> In contrast&#44; in the paraisthmic approach&#44; a foramen lesion can easily be resolved without removing isthmus because at upper lumbar levels such as at L2-3 or L3-4&#44; isthmuses are located further in relative to the intervertebral foramen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; this is not the case in some lesions at L4-5 and most lesions at L5-S1&#46; Accordingly&#44; for lesions at the L5-S1 level&#44; the authors attempted to remove foraminal or extraforaminal disc materials without performing lateral facetectomy or removing isthmus by using an extreme lateral approach&#46; With the ELIA approach&#44; it was possible to resolve most lesions without involving the facet joint&#44; and excellent outcomes on pain and K-ODI was observed during the follow-up in comparison with following the CIPA approach&#46; Even in cases with facet arthropathy&#44; access was possible through minimal superior facet undercutting&#44; and the facet joint was never involved&#46; With respect to reoperation&#44; 31&#46;4&#37; of patients in the CIPA group underwent reoperation&#44; whereas none did so in the ELIA group&#46; Of course&#44; the follow-up period was relatively short and statistical significance was not obtained&#44; but the authors believe that the statistics are meaningful in their own right&#46; The study has limitations in that it was a retrospective study&#44; and its sample size was relatively small&#46; And the total follow-up period was relatively short&#46; And there were not exact records about last follow-up outcome&#46; It was because of retrospective study&#46; In the future&#44; an effort should be made to derive more meaningful outcomes by using a larger sample and by observing patients for a longer follow-up period&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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              "titulo" => "Introduction and objectives"
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          "titulo" => "Introduction"
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              "titulo" => "Surgical technique"
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    "fechaRecibido" => "2018-04-30"
    "fechaAceptado" => "2018-07-29"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1082900"
          "palabras" => array:4 [
            0 => "Combined approach"
            1 => "Disc herniation"
            2 => "Lumbosacral junction"
            3 => "Lumbar"
          ]
        ]
        1 => array:4 [
          "clase" => "abr"
          "titulo" => "Abbreviations"
          "identificador" => "xpalclavsec1082899"
          "palabras" => array:6 [
            0 => "ELIA"
            1 => "CIPA"
            2 => "CT"
            3 => "MRI"
            4 => "K-ODI"
            5 => "NRS"
          ]
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      ]
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          "palabras" => array:4 [
            0 => "Abordaje combinado"
            1 => "Hernia discal"
            2 => "Uni&#243;n lumbosacra"
            3 => "Lumbar"
          ]
        ]
      ]
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    "resumen" => array:2 [
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are several approaches for double disc herniation consisting of an intracanal and foraminal lesion&#46; Of several approaches&#44; we introduced extreme lateral and interlaminar approach &#40;ELIA&#41;&#46; And we aimed to compare the approach with the conventional combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level between March 2012 and February 2016 and patients who underwent CIPA or ELIA were selected&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; For postoperative outcomes&#44; the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation were checked&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eleven patients were given ELIA and twenty-four patients were involved in CIPA&#46; The mean pre K-ODI was 34&#46;1 &#40;&#177;13&#46;9&#41; and 32&#46;4 &#40;&#177;4&#46;0&#41; at each group&#46; 1st&#44; 2nd and 3rd month post-operative K-ODI was 8&#46;2 &#40;&#177;4&#46;1&#41;&#44; 6&#46;4 &#40;&#177;2&#46;1&#41; and 5&#46;3 &#40;&#177;2&#46;4&#41; in ELIA and 8&#46;1 &#40;&#177;3&#46;2&#41;&#44; 7&#46;1 &#40;&#177;3&#46;5&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; in CIPA&#46; Post-operative 3rd month K-ODI showed significant difference between two groups &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41;&#46; The mean pre NRS was 8 &#40;&#177;0&#46;9&#41; and 8&#46;6 &#40;&#177;1&#46;0&#41;&#46; 1st&#44; 2nd and 3rd month post-operative NRS was 2&#46;4 &#40;&#177;1&#46;5&#41;&#44; 2&#46;2 &#40;&#177;1&#46;5&#41; and 2&#46;0 &#40;&#177;0&#46;9&#41; in ELIA and 3&#46;3 &#40;&#177;1&#46;4&#41;&#44; 3&#46;3 &#40;&#177;1&#46;6&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41;&#46; Post-operative 3rd month NRS showed significant difference between two groups as well &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41;&#46; There were four &#40;19&#46;0&#37;&#41; recurrence cases in CIPA patients group&#44; otherwise there was no recurrence case in ELIA group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span>"
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          0 => array:2 [
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            "titulo" => "Patients and methods"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existen varios tipos de abordajes para la hernia discal doble formada por una lesi&#243;n intracanal y foraminal&#46; Hemos elegido el Abordaje Extremo Lateral e Interlaminar &#40;ELIA&#44; por su sigla en ingl&#233;s&#41; con el objetivo de compararlo con el Abordaje Interlaminar y Para&#237;stmico Convencional combinado &#40;CIPA&#44; por su sigla en ingl&#233;s&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los autores revisaron los cuadros m&#233;dicos de pacientes que se vieron sometidos a un procedimiento para una hernia discal doble a nivel lumbosacro entre marzo del 2012 y febrero del 2016&#44; y se seleccionaron los pacientes que se sometieron a CIPA o a ELIA&#46; Como pruebas preoperatorias&#44; se realizaron radiograf&#237;as simples&#44; tomograf&#237;as computarizadas &#40;CT&#44; por su sigla en ingl&#233;s&#41;&#44; y escaneos de im&#225;genes de resonancia magn&#233;tica &#40;MRI&#44; por su sigla en ingl&#233;s&#41;&#46; Para resultados postoperatorios&#44; se revis&#243; la versi&#243;n coreana del &#205;ndice de Discapacidad Owestry &#40;K-ODI&#44; por su sigla en ingl&#233;s&#41; y la Escala de Estimaci&#243;n Num&#233;rica &#40;NRS&#44; por su sigla en ingl&#233;s&#41; a intervalos postoperatorios de uno&#44; dos y tres meses&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Once pacientes fueron sometidos a ELIA y veinticuatro pacientes a CIPA&#46; La media antes de K-ODI fue 34&#44;1 &#40;&#177;13&#44;9&#41; y 32&#44;4 &#40;&#177;4&#44;0&#41; en cada grupo&#46; El resultado K-ODI para el 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 8&#44;2 &#40;&#177;4&#44;1&#41;&#44; 6&#44;4 &#40;&#177;2&#44;1&#41; y 5&#44;3 &#40;&#177;2&#44;4&#41; en ELIA y 8&#44;1 &#40;&#177;3&#44;2&#41;&#44; 7&#44;1 &#40;&#177;3&#44;5&#41; y 8&#44;4 &#40;&#177;6&#44;4&#41; en CIPA&#46; El resultado postoperatorio K-ODI del 3&#176; mes mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;005&#41;&#46; La media antes del NRS fue de 8 &#40;&#177;0&#44;9&#41; y 8&#44;6 &#40;&#177;1&#44;0&#41;&#46; El resultado del NRS del 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 2&#44;4 &#40;&#177;1&#44;5&#41;&#44; 2&#44;2 &#40;&#177;1&#44;5&#41; y 2&#44;0 &#40;&#177;0&#44;9&#41; en ELIA y 3&#44;3 &#40;&#177;1&#44;4&#41;&#44; 3&#44;3 &#40;&#177;1&#44;6&#41; y 3&#44;7 &#40;&#177;1&#44;9&#41;&#46; El resultado del NRS para el 3&#176; mes postoperatorio tambi&#233;n mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;001&#41;&#46; Hubo cuatro casos de recurrencia en el grupo de pacientes sometidos a CIPA &#40;19&#44;0&#37;&#41;&#44; mientras que&#44; por el contrario&#44; no existi&#243; recurrencia en el grupo de pacientes sometidos a ELIA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el tratamiento de hernia discal doble L5-S1&#44; el abordaje quir&#250;rgico ELIA mostr&#243; mejores resultados que el abordaje quir&#250;rgico CIPA con respecto a dolor y resultados de K-ODI durante los ex&#225;menes de seguimiento a intermedio conducidos durante los tres meses posteriores a la cirug&#237;a&#46;</p></span>"
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          "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Pre &#40;A&#58; sagittal&#44; B&#58; axial&#41; and post &#40;C&#58; sagittal&#44; D&#58; axial&#41; MR image&#46; Yellow arrow&#58; the lesion of disc herniation&#59; yellow ring&#58; the removal site of disc material&#59; red arrow&#58; skin incision site&#46;</p>"
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          "leyenda" => "<p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">ELIA&#58; extreme lateral and interlaminar approach&#59; CIPA&#58; combined interlaminar and paraisthmic approach&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">ELIA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Sex &#40;male&#58;female&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Age &#40;years&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">63&#46;6 &#40;&#177;13&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;62&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean duration of complaints &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">3&#46;8 &#40;&#177;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">4&#46;5 &#40;&#177; 3&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  <table border="0" frame="\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;1 &#40;&#177;3&#46;3&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">32&#46;4 &#40;&#177;4&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;1 &#40;&#177;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 2nd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;4 &#40;&#177;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;1 &#40;&#177;3&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 3rd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;3 &#40;&#177;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4 &#40;&#177;6&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre NRS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8 &#40;&#177;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;6 &#40;&#177;1&#46;0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 1st month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;4 &#40;&#177;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#40;&#177;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 2nd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;2 &#40;&#177;1&#46;5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;3 &#40;&#177;1&#46;6&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">NRS 3rd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;0 &#40;&#177;0&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&#46;7 &#40;&#177;1&#46;9&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "leyenda" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">HNP&#58; herniation of nucleus pulposus&#59; CIPA&#58; combined interlaminar and paraisthmic approach&#59; PLIF&#58; posterior lumbar interbody fusion&#59; TLIF&#58; transforaminal lumbar interbody fusion&#46;</p>"
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Foraminal stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Re-operation cases&#46;</p>"
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:29 [
            0 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Frequency and specific surgical management of far lateral lumbar disc herniations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:2 [
                            0 => "H&#46;R&#46; Siebner"
                            1 => "K&#46; Faulhauer"
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                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Acta Neurochir &#40;Wien&#41;"
                        "fecha" => "1990"
                        "volumen" => "105"
                        "paginaInicial" => "124"
                        "paginaFinal" => "131"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0155"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lateral lumbar disc herniations"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "S&#46;E&#46; Faust"
                            1 => "T&#46;B&#46; Ducker"
                            2 => "J&#46;A&#46; Van Hassent"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "J Spinal Disord"
                        "fecha" => "1992"
                        "volumen" => "5"
                        "paginaInicial" => "97"
                        "paginaFinal" => "103"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/1571619"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0160"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Lateral decompression of a pathological disc in the treatment of lumbar pain and sciatica"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "A&#46; Monteiro"
                            1 => "R&#46; Lefever"
                            2 => "G&#46; Pieters"
                            3 => "E&#46; Wilmet"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Clin Orthop Relat Res"
                        "fecha" => "1989"
                        "volumen" => "238"
                        "paginaInicial" => "56"
                        "paginaFinal" => "63"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0165"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "A posterolateral microsurgical approach to extreme-lateral lumbar disc herniation"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:3 [
                            0 => "M&#46;F&#46; O&#8217;Brien"
                            1 => "D&#46; Peterson"
                            2 => "H&#46;A&#46; Crockard"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.3171/jns.1995.83.4.0636"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Neurosurg"
                        "fecha" => "1995"
                        "volumen" => "83"
                        "paginaInicial" => "636"
                        "paginaFinal" => "640"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7674013"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0170"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Evaluation of varied surgical approaches used in the management of 170 far-lateral lumbar disc herniations&#58; indications and results"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "N&#46;E&#46; Epstein"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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Clinical Research
Extreme lateral and interlaminar approach for intra-canal and foraminal double disc herniation at lumbosacral level
Abordaje lateral extremo e interlaminar a hernias discales foraminales e intracanal a nivel lumbosacro
Jung-Sik Baea, Ki Joon Kimb, Mun Soo Kanga, Il-Tae Jangc,
Autor para correspondencia
nanoori_research@naver.com

Corresponding author.
a Department of Neurosurgery, Nanoori Gangseo Hospital, 187, Garogongwon-ro, Gangseo-gu, Seoul 07718, Republic of Korea
b Department of Neurosurgery, Nanoori Suwon Hospital, 295, Jungbu-daero, Yeongtong-gu, Suwon-si, Gyeonggi-do 16503, Republic of Korea
c Department of Neurosurgery, Nanoori Gangnam Hospital, 731, Eonju-ro, Gangnam-gu 06048, Republic of Korea
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1</a>&#41;&#46; In such a case&#44; total facetectomy or fusion surgery is performed to address both lesions&#44;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#8211;7</span></a> but a combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#44; which is cost-effective and less invasive&#44; may also be utilized&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8</span></a> Because in most cases at the lumbosacral &#40;lumbar 5 &#40;L5&#41; &#8211; sacrum 1 &#40;S1&#41;&#41; level&#44; the isthmus and the facet joint are located in the exterior to the intervertebral foramen&#44; partial facetectomy is often performed in the conventional paraisthmic approach &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; In cases with a double lesion&#44; medial facetectomy is performed in parallel&#44; and so the risk of instability is high following CIPA at the L5-S1 level due to facet joint disruption or post-operative spondylolysis&#46; Accordingly&#44; in the present study&#44; the authors aimed to introduce the extreme lateral and interlaminar approach &#40;ELIA&#41;&#44; which can minimize facetectomy to prevent postoperative instability in cases with a double disc herniation at the L5-S1 level&#44; and to compare the approach with the conventional CIPA procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level &#40;lumbar 5-sacral 1&#41; between March 2012 and February 2016 at the study hospital&#46; Only those patients who underwent CIPA or ELIA were selected&#46; The present study was a retrospective study&#44; and was conducted based on patient records&#44; surgical records&#44; and imaging data&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; The presence of spondylolysis and instability was determined using dynamic X-ray&#44; and double disc herniation was diagnosed using MRI &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; CT was performed as a secondary test&#44; and the presence of a limbus fracture or a calcified disc in the endplate was examined using the CT&#46; In addition&#44; patient gender and age&#44; the length of post-operative follow-up&#44; the surgical approach used&#44; and whether a reoperation was performed were considered&#46; For postoperative outcomes&#44; the groups who underwent CIPA and ELIA&#44; respectively&#44; were compared with respect to the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation&#46; Patients showing spondylolysis&#44; spondylolisthesis&#44; or instability were excluded&#46; All surgeries were performed by one surgeon&#46; The institutional review board approved this study &#40;IRB No&#46; NR-IRB 2016-021&#41;&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Statistical analysis</span><p id="par0015" class="elsevierStylePara elsevierViewall">Statistical analysis was conducted with SPSS 12&#46;0 for Windows &#40;SPSS&#44; Inc&#46;&#44; Chicago&#44; IL&#44; USA&#41;&#46; Postoperative K-ODI and NRS were compared using Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; and whether a reoperation was performed in the groups was compared using Fischer&#39;s exact test&#46; Statistical significance was noted if the <span class="elsevierStyleItalic">p</span> value was less than 0&#46;05&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Surgical technique</span><p id="par0020" class="elsevierStylePara elsevierViewall">Patients were placed with prone position&#46; And the procedure was done under general anesthesia&#46; First&#44; the herniated disc material was removed in the intracanal area using the standard interlaminar approach&#46; To prevent postsurgical spondylolysis that can occur due to excessive laminotomy&#44; laminotomy at L5 was minimized as much as possible&#46; All the procedure of laminotomy and discectomy were performed by using surgical microscope&#46; Decompression at the S1 root was confirmed by performing laminotomy in the upper portion of the sacral laminar&#46; Subsequently&#44; an extreme lateral approach &#40;ELA&#41; was performed to decompress the L5 root pressured in the intervertebral foramen&#46; The angle at which to access the intervertebral foramen without violating the facet joint and the appropriate location for making the skin incision were determined using a preoperative MRI image&#46; The skin incision was performed approximately 7&#8211;9<span class="elsevierStyleHsp" style=""></span>cm away from the midline &#40;<a class="elsevierStyleCrossRefs" href="#fig0015">Figs&#46; 3 and 4</a>&#41;&#46; While the approach angle was roughly estimated&#44; the paraspinal muscle was obliquely dissected and then the facet joints at L4-5 and L5-S1 were examined&#46; Afterwards&#44; a self-retaining Magana retractor was used and the isthmus at L5 was examined by sufficiently dissecting the muscle&#46; In the absence of facet joint hypertrophy&#44; access at an oblique angle enabled the examination of the lower portion of the facet joint&#44; where the root was passing through&#44; via muscle and ligament dissection&#46; The L5 root was immediately examined through a sufficient and careful dissection of the ligaments&#46; To prevent L5 nerve root injury during dissection of the intervertebral ligament&#44; we started dissection at the caudal portion where L5 nerve root did not exist&#46; Upper portion&#44; especially at the junction of L5 transverse process and isthmus&#44; L5 nerve root usually passes through&#46; After finding out perineural fat zone&#44; we did meticulous dissection to check L5 root and L5 pedicle&#46; After the L5 root and L5 pedicle were examined&#44; the root was carefully retracted to examine the herniated disc material and then&#44; the disc material was removed &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Fig&#46; 5</a>&#41;&#46; For complete root decompression&#44; the sacral ala was partially removed in the extraforaminal area and finally&#44; the freely moving root was examined&#46; If hypertrophy due to arthropathy in the facet joint was present&#44; only a partial removal of the lower portion of S1 superior facet provided sufficient visibility&#46; In some cases&#44; visibility at the skin incision site was obstructed by the iliac bone&#44; in which case a small portion of the iliac bone was removed to obtain visibility at the site&#46;</p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Results</span><p id="par0025" class="elsevierStylePara elsevierViewall">A total of 35 patients underwent CIPA or ELIA at the study hospital to treat a double disc herniation at the L5-S1 level between March 2012 and February 2016&#46; Of those&#44; 14 patients were male and 21 were female&#44; and the mean age was 63&#46;4 &#40;&#177;13&#46;7&#41; years&#46; In the ELIA group&#44; there were a total of 11 patients &#40;three men and eight women&#41; and the mean age was 63&#46;0 &#40;&#177;13&#46;9&#41; years&#44; while in the CIPA group&#44; there were a total of 24 patients &#40;11 men and 13 women&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; The mean follow-up length was 11&#46;1 &#40;&#177;4&#46;7&#41; months in the ELIA group and 18&#46;3 &#40;&#177;10&#46;1&#41; months in the CIPA group&#46; The mean operation time was 88&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;14&#46;5&#41; in ELIA and 86&#46;8<span class="elsevierStyleHsp" style=""></span>min &#40;&#177;10&#46;1&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;652&#41;&#46; The preoperative K-ODI score was 34&#46;1 &#40;&#177;3&#46;3&#41; months in the ELIA group and 32&#46;4 &#40;&#177;4&#46;0&#41; months in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;23&#41;&#46; Postoperative K-ODI scores in the ELIA and the CIPA groups were 8&#46;2 &#40;&#177;4&#46;1&#41; and 8&#46;1 &#40;&#177;3&#46;2&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;97&#41; at month one&#59; 6&#46;4 &#40;&#177;2&#46;1&#41; and 7&#46;1 &#40;&#177;3&#46;5&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;54&#41; at month two&#59; and 5&#46;3 &#40;&#177;2&#46;4&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41; at month three&#44; respectively&#46; Thus&#44; only the postoperative K-ODI scores at month three showed a significant between-group difference&#46; Additionally&#44; the preoperative NRS score was 8 &#40;&#177;0&#46;9&#41; in the ELIA group and 8&#46;6 &#40;&#177;1&#46;0&#41; in the CIPA group &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41;&#46; Postoperative NRS scores in the ELIA and the CIPA groups were 2&#46;4 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;&#177;1&#46;4&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;1&#41; at month one&#59; 2&#46;2 &#40;&#177;1&#46;5&#41; and 3&#46;3 &#40;1&#46;6&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;063&#41; at month two&#59; and 2&#46;0 &#40;&#177;0&#46;9&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41; &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41; at month three&#44; respectively&#46; Again&#44; only the postoperative NRS at month three showed a significant between-group difference &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46; There were four patients who underwent reoperation&#44; all of whom belonged to the CIPA group&#46; In those cases&#44; the mean time interval was 12&#46;8 months&#46; Three patients suffered from recurred lumbar disc herniation and one patient had foraminal stenosis&#46; All lesions were due to post-operative instability&#46; All patients underwent posterior intervertebral body fusion surgery&#46; The proportion of reoperation was 0&#37; in the ELIA group and 31&#46;4&#37; in the CIPA group&#44; and the <span class="elsevierStyleItalic">p</span>-value was 0&#46;29 &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">The intracanal and foraminal lumbar disc herniation lesions can cause double radicular compression&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;9&#44;10</span></a> Such lesions are difficult to treat with surgery&#46; Several surgical techniques have been introduced in the treatment of double lumbar disc herniation&#46; The simplest is to remove the intracanal disc material following the interlaminar approach and then to remove the disc material of the foraminal lesion following extended medial facetectomy&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;11&#8211;13</span></a> However&#44; in this approach&#44; the extra foraminal lesion is not accessible and&#44; even though an attempt is made to remove the disc material of the foraminal lesion&#44; it is highly likely for some to be left behind&#46; Another disadvantage is that if medial facetectomy is excessively performed&#44; the risk of instability is high due to postoperative spondylolysis or facet disruption&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;14&#8211;16</span></a> Accordingly&#44; some authors have recommended performing total facetectomy in parallel&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;6&#44;13&#44;16</span></a> However&#44; this approach has also been criticized because of a high risk of postoperative instability or chronic pain after surgery&#46; Thus&#44; there are authors who recommend performing intervertebral fusion surgery after total facetectomy to treat double lumbar disc herniation&#46;<a class="elsevierStyleCrossRefs" href="#bib0170"><span class="elsevierStyleSup">5&#44;17</span></a> Notably&#44; though&#44; fusion surgery takes a relatively long time and causes a large amount of blood loss&#44; increasing the risk for various complications&#46; It is also expensive&#46; For direct access to the foramen&#44; pars interarticularis fenestration has been introduced by Di Lorenzo and colleagues&#44;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a> but this approach is disadvantageous in that only limited exposure is possible&#44; and that there is a concern about a postoperative fracture of the pars&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> Hence&#44; the CIPA approach was introduced by some authors&#44; and many advantages of the approach have been highlighted&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">7&#44;8&#44;20&#44;21</span></a> In CIPA&#44; the transversing root and the exiting root are simultaneously visible&#44; and the lesion can be removed without destroying the facet joint&#44; resulting in a low likelihood of postoperative instability&#46; Particularly&#44; the paraisthmic approach is a very useful surgical technique&#44; as access to the foramen is possible only with a partial removal of the superior-lateral portion of the facet joint&#46;<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">22&#8211;25</span></a> However&#44; the problem is that when this approach is used at the L5-S1 level&#44; excessive facetectomy or excessive removal of isthmus can happen&#46;<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">26&#8211;28</span></a> The lateral pars at L5 are located up to the outer portion of the intervertebral foramen&#44; unlike those at other levels&#44; and thus&#44; an excessive removal of isthmus is necessary to completely expose the foramen&#46;<a class="elsevierStyleCrossRefs" href="#bib0285"><span class="elsevierStyleSup">28&#44;29</span></a> In contrast&#44; in the paraisthmic approach&#44; a foramen lesion can easily be resolved without removing isthmus because at upper lumbar levels such as at L2-3 or L3-4&#44; isthmuses are located further in relative to the intervertebral foramen &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; However&#44; this is not the case in some lesions at L4-5 and most lesions at L5-S1&#46; Accordingly&#44; for lesions at the L5-S1 level&#44; the authors attempted to remove foraminal or extraforaminal disc materials without performing lateral facetectomy or removing isthmus by using an extreme lateral approach&#46; With the ELIA approach&#44; it was possible to resolve most lesions without involving the facet joint&#44; and excellent outcomes on pain and K-ODI was observed during the follow-up in comparison with following the CIPA approach&#46; Even in cases with facet arthropathy&#44; access was possible through minimal superior facet undercutting&#44; and the facet joint was never involved&#46; With respect to reoperation&#44; 31&#46;4&#37; of patients in the CIPA group underwent reoperation&#44; whereas none did so in the ELIA group&#46; Of course&#44; the follow-up period was relatively short and statistical significance was not obtained&#44; but the authors believe that the statistics are meaningful in their own right&#46; The study has limitations in that it was a retrospective study&#44; and its sample size was relatively small&#46; And the total follow-up period was relatively short&#46; And there were not exact records about last follow-up outcome&#46; It was because of retrospective study&#46; In the future&#44; an effort should be made to derive more meaningful outcomes by using a larger sample and by observing patients for a longer follow-up period&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Funding</span><p id="par0040" class="elsevierStylePara elsevierViewall">This research did not receive any specific grant from funding agencies in the public&#44; commercial&#44; or not-for-profit sectors&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Conflicts of interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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            1 => "Disc herniation"
            2 => "Lumbosacral junction"
            3 => "Lumbar"
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          "titulo" => "Abbreviations"
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            0 => "ELIA"
            1 => "CIPA"
            2 => "CT"
            3 => "MRI"
            4 => "K-ODI"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction and objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There are several approaches for double disc herniation consisting of an intracanal and foraminal lesion&#46; Of several approaches&#44; we introduced extreme lateral and interlaminar approach &#40;ELIA&#41;&#46; And we aimed to compare the approach with the conventional combined interlaminar and paraisthmic approach &#40;CIPA&#41;&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors reviewed the medical charts of patients who underwent a procedure for a double disc herniation at the lumbosacral level between March 2012 and February 2016 and patients who underwent CIPA or ELIA were selected&#46; For preoperative testing&#44; simple X-ray&#44; computed tomography &#40;CT&#41;&#44; and magnetic resonance imaging &#40;MRI&#41; scans were performed&#46; For postoperative outcomes&#44; the Korean version of the Oswestry Disability Index &#40;K-ODI&#41; and Numeric Rating Scale &#40;NRS&#41; at one&#44; two&#44; and three months post-operation were checked&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Eleven patients were given ELIA and twenty-four patients were involved in CIPA&#46; The mean pre K-ODI was 34&#46;1 &#40;&#177;13&#46;9&#41; and 32&#46;4 &#40;&#177;4&#46;0&#41; at each group&#46; 1st&#44; 2nd and 3rd month post-operative K-ODI was 8&#46;2 &#40;&#177;4&#46;1&#41;&#44; 6&#46;4 &#40;&#177;2&#46;1&#41; and 5&#46;3 &#40;&#177;2&#46;4&#41; in ELIA and 8&#46;1 &#40;&#177;3&#46;2&#41;&#44; 7&#46;1 &#40;&#177;3&#46;5&#41; and 8&#46;4 &#40;&#177;6&#46;4&#41; in CIPA&#46; Post-operative 3rd month K-ODI showed significant difference between two groups &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;005&#41;&#46; The mean pre NRS was 8 &#40;&#177;0&#46;9&#41; and 8&#46;6 &#40;&#177;1&#46;0&#41;&#46; 1st&#44; 2nd and 3rd month post-operative NRS was 2&#46;4 &#40;&#177;1&#46;5&#41;&#44; 2&#46;2 &#40;&#177;1&#46;5&#41; and 2&#46;0 &#40;&#177;0&#46;9&#41; in ELIA and 3&#46;3 &#40;&#177;1&#46;4&#41;&#44; 3&#46;3 &#40;&#177;1&#46;6&#41; and 3&#46;7 &#40;&#177;1&#46;9&#41;&#46; Post-operative 3rd month NRS showed significant difference between two groups as well &#40;<span class="elsevierStyleItalic">p</span>&#58; 0&#46;001&#41;&#46; There were four &#40;19&#46;0&#37;&#41; recurrence cases in CIPA patients group&#44; otherwise there was no recurrence case in ELIA group&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">In the treatment of L5-S1 double disc herniation&#44; the ELIA surgical approach showed better outcomes than the CIPA surgical approach did with respect to pain and K-ODI during a mid-term follow-up examination conducted three months post-operation&#46;</p></span>"
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        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n y Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Existen varios tipos de abordajes para la hernia discal doble formada por una lesi&#243;n intracanal y foraminal&#46; Hemos elegido el Abordaje Extremo Lateral e Interlaminar &#40;ELIA&#44; por su sigla en ingl&#233;s&#41; con el objetivo de compararlo con el Abordaje Interlaminar y Para&#237;stmico Convencional combinado &#40;CIPA&#44; por su sigla en ingl&#233;s&#41;&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Los autores revisaron los cuadros m&#233;dicos de pacientes que se vieron sometidos a un procedimiento para una hernia discal doble a nivel lumbosacro entre marzo del 2012 y febrero del 2016&#44; y se seleccionaron los pacientes que se sometieron a CIPA o a ELIA&#46; Como pruebas preoperatorias&#44; se realizaron radiograf&#237;as simples&#44; tomograf&#237;as computarizadas &#40;CT&#44; por su sigla en ingl&#233;s&#41;&#44; y escaneos de im&#225;genes de resonancia magn&#233;tica &#40;MRI&#44; por su sigla en ingl&#233;s&#41;&#46; Para resultados postoperatorios&#44; se revis&#243; la versi&#243;n coreana del &#205;ndice de Discapacidad Owestry &#40;K-ODI&#44; por su sigla en ingl&#233;s&#41; y la Escala de Estimaci&#243;n Num&#233;rica &#40;NRS&#44; por su sigla en ingl&#233;s&#41; a intervalos postoperatorios de uno&#44; dos y tres meses&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Once pacientes fueron sometidos a ELIA y veinticuatro pacientes a CIPA&#46; La media antes de K-ODI fue 34&#44;1 &#40;&#177;13&#44;9&#41; y 32&#44;4 &#40;&#177;4&#44;0&#41; en cada grupo&#46; El resultado K-ODI para el 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 8&#44;2 &#40;&#177;4&#44;1&#41;&#44; 6&#44;4 &#40;&#177;2&#44;1&#41; y 5&#44;3 &#40;&#177;2&#44;4&#41; en ELIA y 8&#44;1 &#40;&#177;3&#44;2&#41;&#44; 7&#44;1 &#40;&#177;3&#44;5&#41; y 8&#44;4 &#40;&#177;6&#44;4&#41; en CIPA&#46; El resultado postoperatorio K-ODI del 3&#176; mes mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;005&#41;&#46; La media antes del NRS fue de 8 &#40;&#177;0&#44;9&#41; y 8&#44;6 &#40;&#177;1&#44;0&#41;&#46; El resultado del NRS del 1&#176;&#44; 2&#176; y 3&#176; mes postoperatorio fue de 2&#44;4 &#40;&#177;1&#44;5&#41;&#44; 2&#44;2 &#40;&#177;1&#44;5&#41; y 2&#44;0 &#40;&#177;0&#44;9&#41; en ELIA y 3&#44;3 &#40;&#177;1&#44;4&#41;&#44; 3&#44;3 &#40;&#177;1&#44;6&#41; y 3&#44;7 &#40;&#177;1&#44;9&#41;&#46; El resultado del NRS para el 3&#176; mes postoperatorio tambi&#233;n mostr&#243; una diferencia significativa entre los dos grupos &#40;p&#58; 0&#44;001&#41;&#46; Hubo cuatro casos de recurrencia en el grupo de pacientes sometidos a CIPA &#40;19&#44;0&#37;&#41;&#44; mientras que&#44; por el contrario&#44; no existi&#243; recurrencia en el grupo de pacientes sometidos a ELIA&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">En el tratamiento de hernia discal doble L5-S1&#44; el abordaje quir&#250;rgico ELIA mostr&#243; mejores resultados que el abordaje quir&#250;rgico CIPA con respecto a dolor y resultados de K-ODI durante los ex&#225;menes de seguimiento a intermedio conducidos durante los tres meses posteriores a la cirug&#237;a&#46;</p></span>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;1 &#40;&#177;3&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 2nd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&#46;4 &#40;&#177;2&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;54&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">K-ODI 3rd month&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;3 &#40;&#177;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pre NRS&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;063&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;001&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</th><th class="td" title="table-head  " align="center" valign="top" scope="col" style="border-bottom: 2px solid black">Reason of re-operation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">73&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Foraminal stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">CIPA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">PLIF&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Recurred HNP&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="7" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Mean value&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Re-operation cases&#46;</p>"
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